Beginner (score = 3) Can hold goniolens but hesitates to move to visualize a different angle.

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Dwayne Patrick
5 years ago
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1 Instructions: Use one form per trainee For each competency, allocate a score to the trainee s level of execution of said skill: Novice (Score = 2), Beginner (Score = 3), Advanced (Score 4), and Competent (Score = 5) Each skill/competency has notes on what each level should be able to demonstrate Please complete this form once at the beginning and once again at the end of their training and to Jinexa Rivera, JinexaRivera@orbisorg Competency Assessment for Orbis Pediatric Glaucoma Training (Surgical) Based and Modified from Ophthalmic Simulated Surgical Competency Assessment Rubric Trabeculectomy with MMC (fornix-based flap, releasable sutures) Date Resident Evaluator Novice (score = 2) Beginner (score = 3) Advanced Beginner (score = 4) Competent (score = 5) Not applicable Done by preceptor (score = 0) Goniotomy Surgeon s position, pt s head position and microscope position Handling of instruments Entrance to AC Identification and approach to angle structures Need to instruct where to Sits temporal to pt s sit and how to position the head but hesitates to pt s head and microscope adjust the direction of pt s head and position of microscope Need to instruct how to hold goniolens to view nasal/temporal angle Unable to enter AC with 25g needle syringe for paracentesis Unable to identify and approach angle structures Can hold goniolens but hesitates to move to visualize a different angle Able to enter AC with 25g needle syringe but with hesitation Able to identify but hesitates to approach angle structures Sits temporal to the eye and position pt s head away from the surgeon and microscope properly to view nasal angle Able to handle goniolens and to visualize angles correctly paracentesis Holds the 25g needle bevel up and air free syringe Can identify and approach angle structures Can perform short sweeps anterior border of trabecular Trainee position correctly during surgery, including the microscope and gives instructions to assistant what to do Able to handle goniolens to visualize angles correctly and able to instruct assistant how to move patient s head and position globe Holds the 25g needle and syringe correctly and able to perform paracentesis with ease Can identify and approach angle structures Can perform short sweeps of needle in one direction with ease

2 Maintaining AC and withdrawal of 25g needle syringe from AC Trabeculotomy Unable to maintain AC and cannot remove/need to instruct how to remove 25g needle in AC Able to maintain AC but unable to withdraw 25g needle syringe from AC meshwork with 25 g needle in one direction Maintains AC with viscoelastic gel / water and can withdraw 25g needle syringe properly from AC Maintains AC with viscoelastic gel / water and can withdraw 25g needle syringe properly from AC with ease Can handle difficult cases Scleral flap Identification of Schlemn s canal Use of trabeculotome Trabeculectomy Unable to make scleral flap Unable to identify Schelmn s canal Unable to insert and rotate trabeculotome Able to make scleral flap but with hesitation Need guidance to identify Schlemn s canal Able to insert and remove trabeculotome but with hesitation Performs scleral flap comfortably Can easily identify Schlemn s canal Can insert and remove trabeculotome with ease trabeculotomy scleral flap with ease and can handle difficult cases Can easily identify Schlemn s canal and associate other angle structures Can insert and remove trabeculotome with ease trabeculotomy Conjunctival incision & Tenon s dissection Not able to perform limbal conjunctival incision, clumsy dissection, conjunctival buttonholes Is able to perform limbal conjunctival incisions, and Tenon s dissection safely, but is inefficient/poor tissue handling perform limbal conjunctival incision, and Tenon s dissection with good tissue handling perform limbal conjunctival incision, and Tenon s dissection with good tissue handling Can identify abnormal findings and handle complicated situations during surgery Haemostasis using bipolar cautery Unable to efficiently achieve haemostasis and/or very excessive use of cautery Is able to achieve haemostasis, but is inefficient/excessive cautery and precisely achieve haemostasis, with sufficient, but not excessive use of cautery and precisely achieve haemostasis, with sufficient, but not excessive use of cautery

3 Safe use of mitomycin C (MMC) Unable to perform basic steps of safe use of MMC: not decisive in placing sponge(s), failure to avoid drips, touching conjunctival edges with sponge, failure to time MMC exposure, or failure to remove sponge without touching conjunctival wound edges Failure to irrigate wound with BSS after MMC sponge removed Is able to perform basic MMC placement and removal, but is inefficient and/or occasionally touches conjunctival wound edges and/or failure to time exposure and/or failure to irrigate wound promptly and vigorously place, and remove MMC sponge, without touching conjunctival edges, accurate timing of exposure, rapid and copious irrigation of wound after removing MMC sponge No MMC drips on eye place, and remove MMC sponge, without touching conjunctival edges, accurate timing of exposure, rapid and copious irrigation of wound after removing MMC sponge No MMC drips on eyeable to handle complicated situations during surgery Scleral incision and paracentesis (with corneal grooves to allow buried releasable sutures) Hesitant/multiple attempts required to make scleral partial thickness incision and/or paracentesis Inaccurate placement /inadequate depth of scleral incision Damage to iris/lens from paracentesis incision Corneal grooves inaccurately placed/too deep Scleral partial thickness incision and/or paracentesis efficiently performed, though hesitant, in correct position, without inadvertent injury to iris/lens Inaccurate/inadequate depth of scleral incision Corneal grooves accurately placed Scleral partial thickness incision and/ paracentesis efficiently performed, in correct position, without inadvertent injury to iris/lens Correct depth of scleral incision Corneal grooves accurately placed, correct depth Scleral partial thickness incision and/ paracentesis efficiently performed, in correct position, without inadvertent injury to iris/lens Correct depth of scleral incision Corneal grooves accurately placed, correct depth Able to handle complicated situations during surgery Formation of scleral flap Unable to form a scleral flap safely without unintended changes in thickness of flap/risk of overly thin flap/risk of entering AC too posteriorly Able to form a scleral flap safely without unintended changes in thickness of flap/risk of overly thin flap/risk of entering AC too posteriorly, but Able to form a scleral flap safely without unintended changes in thickness of flap/risk of overly thin flap/risk of entering AC too posteriorly, efficiently Able to form a scleral flap safely without unintended changes in thickness of flap/risk of overly thin flap/risk of entering AC too posteriorly, efficiently Can

4 hesitant, and not efficient handle challenging situations during surgery Full thickness corneal incision into anterior chamber (AC) and formation of sclerostomy with punch Unable to efficiently enter a full- AC, unable to insert punch thickness corneal to perform sclerostomy incision, though hesitant, able to use punch to form sclerostomy, though hesitant, with multiple attempts Able to make fullthickness corneal incision into AC efficiently, and at first attempt Able to use punch efficiently to form a full-thickness sclerostomy Able to make full-thickness corneal incision into AC efficiently, and at first attempt Able to use punch efficiently to form a fullthickness sclerostomy Can handle unexpected situation during surgery Peripheral iridectomy Placement of (temporary) flap sutures Placement of releasable scleral flap sutures Unable to retract iris and perform full-thickness iridectomy Is unable to place and tie scleral flap sutures Is unable to place and tie releasable scleral flap sutures Able to retract iris, but unable to complete fullthickness iridectomy Is able to eventually place and tie flap sutures, but inefficient/multiple attemptsfailure to reform AC Is able to eventually place and tie flap releasable sutures, cut and remove temporary flap sutures, but inefficient/multiple attempts, and corneal loops not buried in cornea Able to retract iris, perform full-thickness iridectomy efficiently, and first attempt on most occasions place and tie scleral flap sutures Prompt, efficient reformation of AC via paracentesis, digital estimation of IOP to ensure not too high place and tie scleral releasable flap sutures, cut and remove temporary flap sutures, with corneal loops of releasable sutures fully buried in cornea via corneal grooves Able to retract iris, perform full-thickness iridectomy efficiently, and first attempt on most occasions Can handle difficult surgical cases place and tie scleral flap sutures Prompt, efficient reformation of AC via paracentesis, digital estimation of IOP to ensure not too highcan handle difficult situations during surgery place and tie scleral releasable flap sutures, cut and remove temporary flap sutures, with corneal loops of releasable sutures fully buried in cornea via corneal grooves

5 Reformation of AC using BSS via paracentesis, titration of IOP to ensure watertight scleral flap, but IOP not excessively high Failure to reform AC, because of too loose, poorly placed releasable sutures Failure to tighten releasable sutures adequately AC successfully reformed, but failure to render scleral flap watertight and/or failure to appreciate that IOP too high (via digital IOP estimation), and need to release IOP via paracentesis AC efficiently reformed, scleral flap confirmed to be watertight efficiently, IOP not excessive (efficient estimation of IOP via digital pressure), but if so, IOP reduced via efficient release of aqueous via paracentesis AC efficiently reformed, scleral flap confirmed to be watertight efficiently, IOP not excessive (efficient estimation of IOP via digital pressure), but if so, IOP reduced via efficient release of aqueous via paracentesis Conjunctival suturing Unable to use 10-0 nylon to close conjunctiva Able to eventually close conjunctiva using 10-0 nylon, but inefficient/multiple attempts/knots not buried and/or suture ends not cut sufficiently short Able to close conjunctiva accurately and efficiently, with high likelihood of watertight closure, knots all buried/no protruding suture ends Able to close conjunctiva accurately and efficiently, with high likelihood of watertight closure, knots all buried/no protruding suture ends Final IOP check using digital IOP estimation, sub-conjunctival injection of antibiotic/steroid avoiding subconjunctival hemorrhage Unable to digitally estimate IOP/recognize hypotony/flat AC Unable to automatically administer subconjunctival injection Able to estimate IOP digitally, but unable to safely deliver subconjunctival injection without risk of significant sub-conjunctival hemorrhage Able to efficiently and accurately estimate final IOP digitally, to understand need to adjust releasable sutures if IOP too low, able to administer sub -conjunctival injection automatically Able to efficiently and accurately estimate final IOP digitally, to understand need to adjust releasable sutures if IOP too low, able to administer subconjunctival injection automatically Can detect and correct abnormal results during surgery Tube Shunt Implant Conjunctival incision Unable to perform conjunctival incision Can perform conjunctival incision but with hesitation conjunctival incision with ease Can easily perform conjunctival incision properly

6 Expose quadrant Placing of tube shunt implant Scleral, corneal, pericardium to patch, cover the implant Occlude tube & closing of conjunctiva Unable to perform exposure of supero temporal quadrant Can perform exposure of supero temporal quadrant but hesitant in dissecting conjunctiva and Tenon s capsule Unable to place tube shunt Can insert but hesitant to implant place tube shunt implant exposure of supero temporal quadrant with delicate dissection of Tenon s capsule Able to place and secure tube shunt implant with 9-0 nylon suture to globe Trim tube, bevel-up, and placed correctly exposure of supero temporal quadrant with delicate dissection of Tenon s capsule Can handle complications during surgery Able to place and secure tube implant with 9-0 nylon suture to globe Trim tube, bevel-up and placed correctlycan handle complications in inserting tube implant Unable to suture Hesitant to suture Can suture Can suture scleral/corneal/pericardium sclera/cornea/pericardium sclera/cornea/pericardium sclera/cornea/pericardium to cover the implant to cover implant to cover implant to cover implant Able to suture difficult cases Unable to occlude tube and close conjunctiva Able to close the conjunctiva but hesitant to occlude tube Able to occlude tube through ligature or stent with 6-0 Vicryl suture and close conjunctiva with 9-0 Vicryl Comfortable occlude tube and close conjunctiva easily and properly Global Indices Tissue handling Tissue handling is often unsafe with inadvertent damage, or excessively aggressive or timid Tissue handling is safe but sometimes requires multiple attempts to achieve desired manipulation of tissue Tissue handling is efficient, fluid and almost always achieves desired tissue manipulation on first attempt Technique of holding suture needle in needle holder Loads needle in proper direction for a forehand pass but sometimes loads incorrectly for backhand pass Loads too close or Loads needle properly for forehand and backhand needle pass but is inefficient and often requires multiple Loads needle properly and efficiently for forehand and backhand needle passes

7 Technique of surgical knot tying too far from the swaged end of the needle Require multiple extra hand maneuvers to make first throw lay flat and/or loosens first throw while attempting to perform the second throw attempts Is able to tie a flat surgeon s knot first throw but second and third throws are inefficient Does not inadvertently loosen the first throw tie a flat, square surgeon s knot Overall Difficulty of Procedure: Simple Intermediate Difficult Good Points: Suggestions for development: Agreed action: Signature of assessor Signature of trainee

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